Healthcare Provider Details

I. General information

NPI: 1871808097
Provider Name (Legal Business Name): PAULINE THAI O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2010
Last Update Date: 08/28/2020
Certification Date: 08/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 VONDERBURG DR
BRANDON FL
33511-5982
US

IV. Provider business mailing address

215 1ST ST N STE. 100
WINTER HAVEN FL
33881-4537
US

V. Phone/Fax

Practice location:
  • Phone: 813-681-1122
  • Fax: 813-684-4924
Mailing address:
  • Phone: 863-299-8908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC4538
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: